Abstract

Background:

One of the main challenges to hospital patient flow and treatment includes the lack of a patient-centered approach, which in turn contributes to non-effective teamwork communication.

Objectives:

To introduce patient-centered approach by implementing electronic clinical pathways to support more effective teamwork communication. To study how to enhance teamwork communication in healthcare by implementing electronic clinical pathways.

Methods:

We propose a research model, integrating the Donbedian model and the socio-technical theory, to investigate the factors that influence teamwork communication in healthcare. This research applied a quantitative approach using a survey method that was designed along the same principles as in the related work. Preliminary data collection was conducted using the survey method for problem formulation.

Results:

Designed and developed a model for implementing electronic clinical pathways to enhance teamwork communication in healthcare.

Unique Statistics:

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

1. INTRODUCTION

The disease-centered approach has been the dominant form of healthcare delivery. In a disease-centered delivery, patients are treated by specialists, without consideration for other medical conditions or medications. Recently, there has been a shift towards a more patient-centered approach, where healthcare delivery keeps in mind all other present conditions. For that to happen, high levels of collaboration and communication among healthcare providers are imminent. This results in better use of resources, better care delivery and fewer diagnostic conflicts.

Clinical pathways [1Yamazaki T, Ikeda M, Umemoto K. Enhancement of healthcare quality using clinical-pathways activities. VINE J Inform Knowledge 2011; 41(1): 63-75., 2Wakamiya S, Yamauchi K. What are the standard functions of electronic clinical pathways? Int J Med Inform 2009; 78(8): 543-50.[http://dx.doi.org/10.1016/j.ijmedinf.2009.03.003] [PMID: 19345608] ] play an instrumental role in the patient-centric healthcare model. They are an international standard that defines a step-by-step treatment path to follow. This means successful communication and collaboration of the main stakeholders in the treatment process. That is physicians, specialists, nurses, emergency room coordinators, administrative staff and pharmacists must work as one team. However, every patient’s treatment process is special and might follow different paths as opposed to other patients. The communications among stakeholders might follow different channels. Moreover, patients with multiple symptoms might follow multiple clinical pathways. Therefore, effective communication among medical staff is essential along all these different clinical pathways. These communications might occur across departments, healthcare facilities and time boundaries. Consequently, treating one patient might include multiple departments, campuses, hospitals, specialists and drugs. This requires high levels of coordination amongst all the above to avoid costly mistakes that will endanger lives.

A comprehensive literature review revealed that there is little research looking at clinical pathways from information systems and teamwork communication perspectives. In addition, there are very few models for implementation and adoption in Healthcare Information Systems (HIS), and the existing models are not extensive and rigorous [3Logan J. Electronic health information system implementation models - a review. Stud Health Technol Inform 2012; 178: 117-23.[PMID: 22797029] ]. Consequently, there is a need for a more comprehensive and rigorous teamwork communication model that takes into account and aligns with social and technical aspects.

Seventy percent of medical errors are attributed to teamwork communication [4Deneckere S, Euwema M, Van Herck P, et al. Care pathways lead to better teamwork: Results of a systematic review. Soc Sci Med 2012; 75(2): 264-8.[http://dx.doi.org/10.1016/j.socscimed.2012.02.060] [PMID: 22560883] ]. Communication can be synchronous and asynchronous, with both having advantages and disadvantages. In using synchronous and asynchronous communication, the most important issue is the lack or inconsistency of patients’ information [5Barretto S, Warren J, Stumptner M, Schrefl M, Quirchmayr G, Nield S. Proceedings of the 35th Annual Hawaii International Conference on 2002; Washington: IEEE 2002.[http://dx.doi.org/10.1109/HICSS.2002.994116] -7Yazdi S. An Ontology Based Framework for Modeling Healthcare Teams. M.Sc. diss., University of Ottawa: Ottaw 2012.]. To confirm and apply the patient-centred approach, there is a need for information systems to support the treatment process. This is lacking in the current HISs, which leads to delay in communications due to inaccessibility of medical records [8Al-Salamah H, Gray A, Morrey D. Mapping the integrated care pathway into BPM for health case management.S-BPM ONE-Education and Industrial Developments 2012; 106-20.[http://dx.doi.org/10.1007/978-3-642-29294-1_8] ]. Therefore, healthcare information systems must provide support for better teamwork communications and information sharing in the clinical pathway.

2. THEORETICAL BACKGROUND

This section presents a review of related work on Information Systems (IS) theories and teamwork communication models with the aim of developing a new model to enhance teamwork communication in healthcare.

2.1. Information Systems and Teamwork Communication Considerations

This research study attempts to highlight the factors that affect the enhancement of teamwork communication by implementing electronic clinical pathways. In spite of the advantages of clinical pathways for teamwork communication, less attention has been paid to exploring physicians and nurses’ use of communication throughout clinical pathways. More than 50% of HISs around the world have failed and very few models incorporate electronic pathways in HISs [3Logan J. Electronic health information system implementation models - a review. Stud Health Technol Inform 2012; 178: 117-23.[PMID: 22797029] ]. In addition, there is a trend to enhance communication and decision making in HISs, which has not yet been achieved [10Quaglini S, Sacchi L, Lanzola G, Viani N. Personalization and patient involvement in decision support systems: Current trends. Yearb Med Inform 2015; 10(1): 106-18.[http://dx.doi.org/10.15265/IY-2015-015] [PMID: 26293857] ].

This research study seeks to enhance teamwork communication in healthcare by implementing electronic clinical pathways. The socio-technical theory and the Donabedian model are integrated for that purpose. In socio-technical theory, IS comprises two subsystems: The technical (technology and process) and the social (people and structure). To attain the full benefits, system designers and developers have to identify how subsystems impact each other [11Mattia A. A multi-dimensional view of socio-technical information systems research and technochange. Review of Business Information Systems 2011; 15(4): 11-8. [RBIS].[http://dx.doi.org/10.19030/rbis.v15i4.6008] , 12Brooks P, El-Gayar O, Sarnikar S. A framework for developing a domain specific business intelligence maturity model: Application to healthcare. Int J Inf Manage 2015; 35(3): 337-45.[http://dx.doi.org/10.1016/j.ijinfomgt.2015.01.011] ]. To enhance the current HISs, there is a need for alignment between technical and social aspects to prevent the failure of systems [13Koppel R, Metlay JP, Cohen A, et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 2005; 293(10): 1197-203.[http://dx.doi.org/10.1001/jama.293.10.1197] [PMID: 15755942] , 14Piscotty RJ, Kalisch B. The relationship between electronic nursing care reminders and missed nursing care. Comput Inform Nurs 2014; 32(10): 475-81.[http://dx.doi.org/10.1097/CIN.0000000000000092] [PMID: 25119428] ].

Many studies have considered how the quality of healthcare systems may be evaluated and assessed [15Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260(12): 1743-8.[http://dx.doi.org/10.1001/jama.1988.03410120089033] [PMID: 3045356] , 16Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q 2005; 83(4): 691-729.[http://dx.doi.org/10.1111/j.1468-0009.2005.00397.x] [PMID: 16279964] ]. The Donabedian model explains three dimensions (structure, process, outcome), which present the whole structure for any information system. Kuziemsky et al, [17Kuziemsky CE, Borycki EM, Purkis ME, et al. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak 2009; 9(1): 43.[http://dx.doi.org/10.1186/1472-6947-9-43] [PMID: 19754966] ] used the Donabedian model to develop an interdisciplinary team communication model. This framework supports interdisciplinary team communication and can serve as a guideline for developers and designers when implementing HISs that support teamwork communication.

2.2. Health Information System Approaches

The current HISs were designed for organizational purposes; thus there is a need to distinguish between the administrative and clinical processes. The current HISs support the administrative processes, but to a limited degree, they include some clinical processes that can support teamwork communication. Consequently, the current HIS has not been designed to support the patients’ treatment processes and does not support communication and coordination of multiple teamworks [18AL-Salamah H. Supporting integrated care pathways with workflow technology. PhD diss, Wales, UK: Cardiff University 2012.-21Swenson KD, Palmer N, Silver B. Taming the Unpredictable: Real World Adaptive Case Management: Case Studies and Practical Guidance 2011.]. HISs have two approaches: the disease-centered and the patient-centered. In the disease-centered approach, physicians treat their patients individually, without considering other conditions and treatments. There is a need to switch from the disease-centered to the patient-centered approach to treat the patient’s case as a whole instead of isolated diseases [18AL-Salamah H. Supporting integrated care pathways with workflow technology. PhD diss, Wales, UK: Cardiff University 2012., 19Ward MM, Jaana M, Bahensky JA, Vartak S, Wakefield DS. Clinical information system availability and use in urban and rural hospitals. J Med Syst 2006; 30(6): 429-38.[http://dx.doi.org/10.1007/s10916-006-9014-3] [PMID: 17233155] , 22 Department of Health., The NHS plan: A plan for investment, a plan for reform in London: 2000, pp. 144]. This approach can support the administrative process, not the clinical processes; in other words, it supports the administrative purpose, and there is a need for a system supporting the clinical processes. This approach lacks supporting teamwork activities, especially communication, and lacks information on the treatment process flow. In addition, it lacks information on when the patient’s disease reached its current stage and what the future implications might be. In a patient-centered approach, physicians treat their patients and take into account all the patient’s diseases as a whole, not in isolation from other conditions. The aim of this approach is to enhance the quality of healthcare and reduce errors. The patient-centered approach supports teamwork activities, and these activities have a primary element that is depicted in communication and coordination. There are two key requirements of the patient-centered approach, teamwork communication and care coordination [18AL-Salamah H. Supporting integrated care pathways with workflow technology. PhD diss, Wales, UK: Cardiff University 2012., 19Ward MM, Jaana M, Bahensky JA, Vartak S, Wakefield DS. Clinical information system availability and use in urban and rural hospitals. J Med Syst 2006; 30(6): 429-38.[http://dx.doi.org/10.1007/s10916-006-9014-3] [PMID: 17233155] , 22 Department of Health., The NHS plan: A plan for investment, a plan for reform in London: 2000, pp. 144-24Luxford K, Safran DG, Delbanco T. Promoting patient-centered care: A qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care 2011; 23(5): 510-5.[http://dx.doi.org/10.1093/intqhc/mzr024] [PMID: 21586433] ]. The patient-centered approach has a set of characteristics illustrated in Table 1 [25Sadeghi P, Kuziemsky C, Benyoucef M. Towards a readiness model for health 2.0. Proceedings of the International Conference on Management of Emergent Digital EcoSystems 2011; ACM Digital Library: San Francisco, California 2011.-27Avison D, Young T. Time to rethink health care and ICT? Commun ACM 2007; 50(6): 69-74.[http://dx.doi.org/10.1145/1247001.1247008] ]. The patient-centered approach supports teamwork activities, including communication and coordination. Finally, effective teamwork communication remains a problem in healthcare due to adverse negative outcomes [28Foshay N, Kuziemsky C. Towards an implementation framework for business intelligence in healthcare. Int J Inf Manage 2014; 34(1): 20-7.[http://dx.doi.org/10.1016/j.ijinfomgt.2013.09.003] ].

Table 1Patient-centered approach characteristics.

2.2.1. Teamwork Communication in Healthcare

Teamwork is a new concept in healthcare. Also, there is a lack of shared decision-making and interdependent collaboration between team members [32Salas E, King HB, Rosen MA. Improving teamwork and safety: Toward a practical systems approach, a commentary on Deneckere et al. Soc Sci Med 2012; 75(6): 986-9.[http://dx.doi.org/10.1016/j.socscimed.2012.02.055] [PMID: 22627017] ] even though communication systems are comprised of messages, people, and transmission systems [33Coiera E. Communication systems in healthcare. Clin Biochem Rev 2006; 27(2): 89-98.[PMID: 17077879] ]. In recent years, much research has been conducted to improve teamwork communication [32Salas E, King HB, Rosen MA. Improving teamwork and safety: Toward a practical systems approach, a commentary on Deneckere et al. Soc Sci Med 2012; 75(6): 986-9.[http://dx.doi.org/10.1016/j.socscimed.2012.02.055] [PMID: 22627017] , 34Bitter J, van Veen-Berkx E, Gooszen HG, et al. Multidisciplinary teamwork is an important issue to healthcare professionals. Team Perform Manage 2013; 19(5/6): 263-78.[http://dx.doi.org/10.1108/TPM-11-2012-0041] ]. Improving teamwork communication requires redesigning the work and process to support more effective communication [35Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JD, van Wijk KP. Interventions to improve team effectiveness: A systematic review. Health Policy 2010; 94(3): 183-95.[http://dx.doi.org/10.1016/j.healthpol.2009.09.015] [PMID: 19857910] ]. The clinical pathways concept and structure supports the patient-centered approach and provides a solution for teamwork communication but more research is still needed. Table 2 presents the trends in teamwork communication in healthcare and the gaps. Consequently, based on Table 2, research on teamwork communication in healthcare is still in its infancy stage. There is need for more research and specific research work on such tools and system which improve and enhance teamwork communication in healthcare.

Table 2Trends in teamwork communication in healthcare.

2.3. Clinical Pathways

The European Pathway Association (EPA) defines clinical pathway as mutual healthcare processes, steps and decisions for similar patients during the same period. The defining characteristics of the clinical pathways include:

Clear healthcare elements from past experience;

Enhanced communication between healthcare professionals and with patients and families;

Clear sequence of steps for healthcare delivery and well-coordinated roles for healthcare professionals, patients and families;

Clinical pathways facilitate the flow of medical records and data through the treatment and reduce medical errors [41Vanhaecht K, Panella M, Van Zelm R, Sermeus W. What about care pathways. Care of Dying.A pathway to excellence 2011; 2-12.]. Medical errors can be divided into diagnostics, treatment, preventive, and others [42Lippi G, Simundic A-M, Mattiuzzi C. Overview on patient safety in healthcare and laboratory diagnostics. Biochem Med (Zagreb) 2010; 20(2): 131-42.[http://dx.doi.org/10.11613/BM.2010.015] ]. A good number of those errors result from the lack of communications as well as improper sharing of data in terms of accuracy and timeliness. Improving the treatment process plays a major role in reducing medical errors. clinical pathways will improve the outcomes of the treatment process. They present the treatment process and design the patient journey by managing the timing, using of Gantt charts, for example [43Panella M, Van Zelm R, Sermeus W, Vanhaecht K, et al. Care pathways for the organization of patients' care. Bulletin: Economics, Organisation and Informatics in Healthcare 2012; 28(2): 111-22.[http://dx.doi.org/10.2478/v10221-011-0026-z] ].

2.3.1. Clinical Pathways Analysis Situation

In spite of the increase in the number of studies on clinical pathways both in the medical domain and in other domains, clinical pathways have continued to be promoted as a communication medium. However, few studies on clinical pathways emanate from Information Systems to help establish it as a reliable means for improving healthcare quality as well as improving and enhancing teamwork communication among medical staff. In the healthcare domain, some tools are deployed to improve communication among medical staff. These include SBAR (Situation, Background, Assessment, and recommendation), a structured communication technique aimed at standardizing communication among medical staff [44Carayon P, Alyousef B, Xie A. Human Factors and Ergonomics in Health Care. In: Salvendy G, Ed. Handbook of Human Factors and Ergonomics 4th ed.. 2012.4th ed..[http://dx.doi.org/10.1002/9781118131350.ch57] , 45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68.], and TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), which provides a framework for performance and safety [46Battles J, King HB. TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ) Manual 2010., 47Hwang J-I, Ahn J. Teamwork and clinical error reporting among nurses in Korean hospitals. Asian Nurs Res (Korean Soc Nurs Sci) 2015; 9(1): 14-20.[http://dx.doi.org/10.1016/j.anr.2014.09.002] [PMID: 25829205] ]. These tools enhance communication among medical staff, but shortcomings exist in the way of providing the information. These shortcomings are based on clinical pathways.

Communication to understand different knowledge among various professionals is improved through clinical pathway activities in healthcare. There is need for directors of clinical pathway activities to consider the importance of the sustainment of flat communication.

A study was carried out on clinical pathways for four years from 2011 to 2014 using Google Scholar. This study aims to study the trend and reveal, which discipline concentrates on clinical pathways. Table 3 expresses the studies on clinical pathways based on four disciplines. Also, Table 4 shows the perspective from which each discipline studies clinical pathways. Fig. (1) is a chart showing the papers published per domain. This study opens new areas to study clinical pathways from four disciplines: computer science, medicine, management and information system.

Fig. (1)
Percentages of papers published per domain.

Table 3Clinical pathways disciplines.

Table 4Clinical pathways domain perspective.

The above situational analysis of clinical pathways leads the researcher to look for developing models and frameworks to enhance teamwork communication in healthcare. The next section illustrates these models and discusses their characteristics.

2.4. Limitations

There is a lack of investigated factors in support of teamwork communication in healthcare. By implementing clinical pathways, the lack of these factors is exposed. Based on these gaps, there is a need to look for a theory or a model to enhance teamwork communication in healthcare. The theory or model should support implementation, development and design. These gaps appear in the inability of supporting clinical pathway processes, such as communication protocols which are useful in supporting standardized communication among medical staff, structuring internal and external communication, sharing and exchanging information among medical staff.

Table 5 explains the gaps in the investigated factors [62Mater W, Ibrahim R. Factors supporting teamwork communication in clinical pathways: Systematic literature review. J Theoretical Appl Inform Technol 2015; 81(3): 481-8.]. Clinical pathways have three processes [63Mater W, Ibrahim R. Standard processes of electronic clinical pathways that support decision making and teamwork communication. Science International, 2014; 26(3).]: The medical process, the administrative process, and the decision-making process. Based on these processes, there is a need to adopt a set of factors or a model to support the mentioned processes of clinical pathways. Based on these issues in this research study, there is a need for a model or a framework to solve these problems. The gaps of these factors, based on matching the issues using clinical pathways processes, are listed below.

First, the initial process of clinical pathways is the medical process. During the matching of the factors to the medical process, we found that no factors support the medical process. In the medical process, there is a need for a set of factors to support the medical process for patients from admission to discharge to make sure that all medical stages are verified and supported to improve healthcare quality and patient safety. In electronic clinical pathways, 5 characteristics of clinical pathways describe medical process structure. Consequently, these characteristics of the medical process have the ability to solve the issues of lack of a system that supports the treatment process and lack of information about the patients’ plan.

Table 5Gaps of investigated factors.

Second, very few factors support the administrative process, the decision-making process, teamwork communication that can solve the issues that are depicted in poor communication and coordination, and delay of communication. The characteristics of these processes need a set of factors to solve the issues and provide a solution to these issues.

Based on the above discussion and the gaps of the investigated factors, there is a need to investigate a theory or a model with its factors to support clinical pathways processes and solve the issues.

2.5. Statement of Methods and Systematic Literature Review

To identify the related researches, we searched three online databases: Medline (PubMed), ScienceDirect, and Scopus, for papers published between January 2010 and December 2013. In addition, Google Scholar was searched to do a more thorough literature search. Three factors effect teamwork communication: teamwork, task, and context. Most of the literature focuses on the teamwork concept, and very little attention is paid to the other two factors. Task and context factors have considerable effects on teamwork, especially in healthcare multidisciplinary teamwork. We wanted to study all factors affecting teamwork communication and what factors and indicators contribute to the success of teamwork communication.

2.6. Summary of Literature Findings

We surveyed information system studies that discuss HIS and clinical pathways, clinical pathways studies in information systems given the problematic history of HIS issues related to a lack of specific details and failure in HIS implementations, and the issues related to HIS and clinical pathways [3Logan J. Electronic health information system implementation models - a review. Stud Health Technol Inform 2012; 178: 117-23.[PMID: 22797029] , 65Robert G, Greenhalgh T, Macfa lane F, Peacoc KR. Organisational factors influencing technology adoption and assimilation in the NHS: A systematic literature review. Report for the National Institute for Health Research Service Delivery and Organisation programme, 2009.]. The studies present the current state of the art in addressing teamwork communication in healthcare. It is apparent that researchers and medical staff in the healthcare domain are expressing their concerns about these issues and are engaging in attempts to mitigate these concerns [66Oosterholt RI, Simonse LW, Boess SU, Vehmeijer SB. Designing a care pathway model - A case study of the outpatient total hip arthroplasty care pathway. Int J Integr Care 2017; 17(1): 2.[http://dx.doi.org/10.5334/ijic.2429] [PMID: 29042844] ]. To date, however, teamwork communication in healthcare has not been adequately addressed, and the issues require further investigation [67Mater W, Ibrahim R. Situation analysis for clinical pathways and teamwork communication in healthcare. Indian J Sci Technol 2016; 9(28)]. It is apparent that it is important to consider social and technical factors that enhance teamwork communication in healthcare.

The current Health Information System is a disease-centered approach [68Vrijhoef HJ, de Belvis AG, de la Calle M, et al. IT-supported integrated care pathways for diabetes: A compilation and review of good practices. Int J Care Coord 2017; 20(1-2): 26-40.[http://dx.doi.org/10.1177/2053434517714427] [PMID: 28690856] ]. This approach has weaknesses to support the teamwork communication, and there is a need to switch to a patient-centered approach. Teamwork communication is a key point of the patient-centered approach. The present patient-centered approach is crucial to facilitate identifying the appropriate factors for enhancing teamwork communication in healthcare to apply the patient-centered approach.

In health informatics science, we must have a model before automating any processes or systems. At present, there is a rush in designing ICT systems for healthcare without an articulate model or framework on how the processes and systems will work [25Sadeghi P, Kuziemsky C, Benyoucef M. Towards a readiness model for health 2.0. Proceedings of the International Conference on Management of Emergent Digital EcoSystems 2011; ACM Digital Library: San Francisco, California 2011., 68Vrijhoef HJ, de Belvis AG, de la Calle M, et al. IT-supported integrated care pathways for diabetes: A compilation and review of good practices. Int J Care Coord 2017; 20(1-2): 26-40.[http://dx.doi.org/10.1177/2053434517714427] [PMID: 28690856] , 69Schriek M, Türetken O, Kaymak U. A maturity model for care pathways 2016.]. Improving Health Information Systems by adopting the patient-centered approach as a new concept to enhance teamwork communication and improve the healthcare service quality needs to implement clinical pathways as one of the systems that support the concept of a patient-centered approach. Enhancing teamwork communication in healthcare by implementing clinical pathways to apply the concept of a patient-centered approach by using the social-technical system to align the social and technical aspects will improve healthcare service quality and patient safety.

3. RESEARCH FRAMEWORK

We seek to integrate the socio-technical theory and the Donabedian model to enhance teamwork communication in healthcare by implementing electronic clinical pathways. Subsection 3.1 explains the development model; subsection 3.2 describes the Donabedian model, which plays a key role in developing the developed model in this research, and Subsection 3.3 describes the research hypotheses.

As mentioned in Table 6, Donabedian provides the most appropriate model to be adapted to this research study. However, in structure dimension, when structuring the internal and external communication, internal communication is concerned with the concept of functioning from within policies and procedures while external communications influence how teams coordinated their work with outside agencies and other members during off-work hours. There is a gap that is unfilled; this gap assimilates in communication protocols, which standardized internal and external communication.

Patient information, poor communication and coordination, and a lack of standard are other issues that should be resolved. To support and resolve this issue, structuring internal and external communication and the communication process should be standardized by adopting communication protocols. Fig. (5) shows the enhancements over the Donabedian Model and Table 7 presents how Donabedian factors support clinical pathways processes.

Table 7Donabedian factors support clinical pathways processes.

Fig. (5)
Enhancement of the donabedian model.

3.3. Hypotheses

Fig. (6) presents the proposed model where structure and people make out the social subsystem while technology and tasks make the technical subsystem. According to Giddens, structure is the rules humans follow while interacting with technology. Additionally, Management Information Systems (MIS) affect the technical subsystem according to Lyytinen and Newman [79Lyytinen K, Newman M. Explaining information systems change: A punctuated socio-technical change model. Eur J Inf Syst 2008; 17(6): 589-613.[http://dx.doi.org/10.1057/ejis.2008.50] ]. Both the social and technical subsystem depend on each other to achieve rational tasks [80Morris A. Socio-Technical Systems in ICT: A comprehensive survey 2009.].

H5: Teamwork structure will have a positive influence on enhancing teamwork communication in healthcare.

Communication between individuals is often “informal, disorganized and variable”. Therefore, there are a number of tools and aids used to enhance teamwork communication such as communication protocols. Communication protocols are defined as “a set of protocols, which use specific terminologies in teamwork communication” [45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68.]. They enhance teamwork communication, information exchange and teamwork cohesion. These protocols enhance handoff between shifts at hospitals [72Haig KM, Sutton S, Whittington J. SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006; 32(3): 167-75.[http://dx.doi.org/10.1016/S1553-7250(06)32022-3] [PMID: 16617948] ]. This study argues that communication protocol factor has an effect on enhancing teamwork communication in healthcare. This study develops hypotheses as stated below:

H6: Communication protocols will have a positive influence on enhancing teamwork communication in healthcare.

H7: Communication protocols will have a mediation role in the association between internal communications and enhance teamwork communication in healthcare.

H8: Communication protocols will have a mediation role in the association between external communications and enhance teamwork communication in healthcare.

Information sharing can be defined as “the amount and frequency of the information shared among teammates” [83Randall KR, Resick CJ, DeChurch LA. Building team adaptive capacity: The roles of sensegiving and team composition. J Appl Psychol 2011; 96(3): 525-40.[http://dx.doi.org/10.1037/a0022622] [PMID: 21319876] ]. During incident management, information sharing is crucial for communication and decision-making; therefore, information sharing is key among the technology factors [84Kim JK, et al. Framework for analyzing Critical Incident Management Systems (CIMS). System Sciences, 2006. HICSS'06. Proceedings of the 39th Annual Hawaii International Conference on. 2006. Kauia: IEEE.]. This study argues that the information sharing factor will has an effect on the enhancement of teamwork communication in healthcare. This study develops a hypothesis as stated below:

H9: Information sharing will have a positive influence on enhancing teamwork communication in healthcare.

H10: Care planning will have a positive influence on enhancing teamwork communication in healthcare.

Ninety percent of healthcare information transactions include information exchange; nonetheless, it was not closely looked at as much as storage [87Toussaint PJ, Coiera E. Supporting communication in health care. Int J Med Inform 2005; 74(10): 779-81.[http://dx.doi.org/10.1016/j.ijmedinf.2005.04.007] [PMID: 15998598] ]. Information exchange that combining and exchanging information results in better value [88Collins CJ, Smith KG. Knowledge exchange and combination: The role of human resource practices in the performance of high-technology firms. Acad Manage J 2006; 49(3): 544-60.[http://dx.doi.org/10.5465/amj.2006.21794671] ]. It has also been defined as “information exchange for the purpose of assisting diagnosis, planning, documenting processes, enabling transfers between areas of responsibility or carry out administrative activities” [89Ammenwerth E, Winter A. Strategic information management in hospitals: An introduction to hospital information systems 2004.]. However, there is a lack of interest in the literature in designing information exchange systems in healthcare [17Kuziemsky CE, Borycki EM, Purkis ME, et al. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak 2009; 9(1): 43.[http://dx.doi.org/10.1186/1472-6947-9-43] [PMID: 19754966] ]. Information exchange is considered as an important part of enhancing teamwork communication in healthcare. This study argues that the information sharing factor has an effect on the enhancement of teamwork communication in healthcare. This study develops a hypothesis as stated below:

H11: Information exchange will have a positive influence on enhancing teamwork communication in healthcare.

H13: Disease planning will have a positive influence on enhancing teamwork communication in healthcare.

4. RESEARCH METHODOLOGY

This study used a paper-based questionnaire to collect data from the respondents. The advantages of a paper-based questionnaire are not only that it takes less time and resources to develop, but it is much easier to manage because what you see is what you get [93Boyer KK, Olson JR, Calantone RJ, Jackson EC. Print versus electronic surveys: A comparison of two data collection methodologies. J Oper Manage 2002; 20(4): 357-73.[http://dx.doi.org/10.1016/S0272-6963(02)00004-9] ].

4.1. Data Collection

Data were collected in person from physicians and nurses at two university hospitals in the Hashemite Kingdom of Jordan. We distributed survey questionnaires in person to physicians and nurses. In total, 677 questionnaires were distributed and 483 collected. There was a good response rate. The sample size was divided into two samples, 160 questionnaires for Exploratory Factor Analysis (EFA) and 323 for Confirmatory Factor Analysis (CFA). To address the samples’ adequacy, we execute the Kaiser-Meyer-Olkin (KMO) test, which measures sample variance. A commendable KMO of 0.81 indicates very good adequacy.

The social aspect or subsystem was presented by a set of factors to achieve the goals and objectives of this research study. The survey measurement of the social aspect contained the concept of teamwork communication types [17Kuziemsky CE, Borycki EM, Purkis ME, et al. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak 2009; 9(1): 43.[http://dx.doi.org/10.1186/1472-6947-9-43] [PMID: 19754966] ], structuring the teamwork [17Kuziemsky CE, Borycki EM, Purkis ME, et al. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak 2009; 9(1): 43.[http://dx.doi.org/10.1186/1472-6947-9-43] [PMID: 19754966] ] and the standardization of the communication between team members [45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68.].

In contrast, the technical aspect is manifested in a set of factors that facilitate and support the social aspect to achieve the goals and objectives of this research study. The survey measurement of the technical aspect included the concepts of care planning, disease planning, discharge planning, information sharing and information exchange [17Kuziemsky CE, Borycki EM, Purkis ME, et al. An interdisciplinary team communication framework and its application to healthcare ‘e-teams’ systems design. BMC Med Inform Decis Mak 2009; 9(1): 43.[http://dx.doi.org/10.1186/1472-6947-9-43] [PMID: 19754966] ] to achieve the goals and objectives of this research study. The scale was articulated and adapted based on the IS literature and previous research works.

4.3. Descriptive Analysis

Table 8 shows that most of the respondents in this study were female (64.4%) and nurses (71.5%). Most were under age 35 (93.8%) and had a bachelor’s degree (72.7%), and most had less than 5 years’ experience in using information technology.

4.5. Assessing of the Measurement Model

In this model, all constructs were reflective; thus, to assess the measurement model, the criteria for assessing of the reflective measurement model had to be considered. The reflective measurement model evaluated reliability and validity, as measured by Composite Reliability (CR) and Average Variance Extracted (AVE) [101Hair JF, Ringle CM, Sarstedt M. PLS-SEM: Indeed a silver bullet. J Mark Theory Pract 2011; 19(2): 139-52.[http://dx.doi.org/10.2753/MTP1069-6679190202] , 105Chin WW. How to write up and report PLS analyses.Handbook of partial least squares 2010; 655-90.[http://dx.doi.org/10.1007/978-3-540-32827-8_29] ]. In the assessment of indicator reliability, the loading of each indicator on its associated latent construct should be higher than 0.7 [106Hair JF. Multivariate data analysis. United Stetes: Prentice Hall 2010.]. However, a loading between 0.4 and 0.7 can be considered acceptable if the CR and AVE of the associated construct are higher than the threshold [101Hair JF, Ringle CM, Sarstedt M. PLS-SEM: Indeed a silver bullet. J Mark Theory Pract 2011; 19(2): 139-52.[http://dx.doi.org/10.2753/MTP1069-6679190202] ].

First, the constructs meet the requirements of reliability given that their loading is, in general, greater than 0.7 as shown in Table 8. To accomplish this result, we carried out a process of item-trimming with some tweaking of clinical pathways, EC, and IE constructs. In addition, we kept some IS and clinical pathwaysL factors that had weak loading to support the validity of the scale and because their Cronbach’s Alpha is high. Second, because all constructs’ composite reliability is greater than 0.7, they have construct reliability. Third, Table 9 shows that the Average Variance Extracted (AVE) is greater than 0.5; therefore, the constructs have a convergent validity. Finally, Tables 10 and 11 show that all variables realize discriminant validity following both the Fornell-Lacker and the HTMT.90 [107Henseler J, Ringle CM, Sarstedt M. A new criterion for assessing discriminant validity in variance-based structural equation modeling. J Acad Mark Sci 2015; 43: 1-21., 108Henseler J, Dijkstra PK, Sarstedt M. Common beliefs and reality about PLS comments on Rönkkö and Evermann (2013). Organizational Research Methods Journal 2014; 17: 182-209.[http://dx.doi.org/10.1177/1094428114526928] ].

Second, direct effects testing of the hypothesis for this study were verified by evaluating the statistical importance of the path coefficients computed by means of the bootstrap resampling method utilizing 5000 samples as shown in Table 13 [100Chin WW. Commentary: Issues and opinion on structural equation modeling MIS Quarterly, 1998. 22(1): pp. vii-xvi., 105Chin WW. How to write up and report PLS analyses.Handbook of partial least squares 2010; 655-90.[http://dx.doi.org/10.1007/978-3-540-32827-8_29] ]. define the bootstrap resampling as a non-parametric method for estimating the precision of the SMART-PLS estimates.

Table 13Structural model: Direct effect.

Third, indirect effects is one of the assessment criterions used to test mediation [110Zhao X, Lynch JG, Chen Q. Reconsidering Baron and Kenny: Myths and truths about mediation analysis. J Consum Res 2010; 37(2): 197-206.[http://dx.doi.org/10.1086/651257] ] as recommended by [111Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods 2008; 40(3): 879-91.[http://dx.doi.org/10.3758/BRM.40.3.879] [PMID: 18697684] , 112Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach 1st Edition ed. New York: Guilford Press, 2013.]. Based on the new concepts of analysis of the effect of mediation, this can be a direct effect or an indirect effect (indirect relationship) [112Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach 1st Edition ed. New York: Guilford Press, 2013.]. In this research study, there is no indirect effect for communication (internal and external) on the enhancement of teamwork communication through communication protocols. According to [108Henseler J, Dijkstra PK, Sarstedt M. Common beliefs and reality about PLS comments on Rönkkö and Evermann (2013). Organizational Research Methods Journal 2014; 17: 182-209.[http://dx.doi.org/10.1177/1094428114526928] ], if VAF > 80%, full mediation is achieved. However, partial mediation is obtained when 20%>= VAF <=80%. No mediation is obtained when VAF < 20%. Table 14 confirms this result.

Table 14Indirect effect.

Fourth, after assessing the path coefficient and R2 values, the next step is to evaluate the effect sizes to investigate the impact and contribution of each exogenous construct towards endogenous latent variables. f2 results are shown in Table 15.

Table 15Effect size (f2).

5. DISCUSSION

Through the gathering and analysis of relevant data, this study shows that internal and external communications are an important trigger for communication protocols, and that teamwork communication in healthcare may be enhanced by implementing electronic clinical pathways. Based on the survey participants beliefs and the presented analysis, the managerial and theoretical implications of the relationships seen across those constructs are discussed as follows.

With regards to H1, the researchers believe based on empirical evidence that internal communication influences the enhancement of teamwork communication in healthcare. This result is corroborated by earlier work [113Choi JN, Kim MU. The organizational application of groupthink and its limitations in organizations. J Appl Psychol 1999; 84(2): 297-306.[http://dx.doi.org/10.1037/0021-9010.84.2.297] ], which encourages structuring communication among team members. Communication will enhance the performance and quality of healthcare that is needed to structure internal communication. In addition, we believe internal communication, H2, either enhances or influences communication protocols. This result is similar to the findings reported by [45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68., 114Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg 2010; 10(1): 43-7.[http://dx.doi.org/10.1510/icvts.2009.217356] [PMID: 19801374] ], which shows that internal communication supports communication protocols. On the other hand, external communication, H3, has an influence on the enhancement of teamwork communication in healthcare, while H4 confirms that external communication may lead to a positive influence on communication protocols.

Additionally, communication protocols may have a positive influence on enhancing teamwork communication in healthcare, H6. This result is similar to the findings reported by [45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68., 114Papaspyros SC, Javangula KC, Adluri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room. Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg 2010; 10(1): 43-7.[http://dx.doi.org/10.1510/icvts.2009.217356] [PMID: 19801374] ], which encourages the structuring and redesigning of communication among team members based on communication protocols. The results for H7 and H8 indicates that the communication protocols could mediate the relationship between internal and external communication and teamwork communication enhancement. According to the participants beliefs, communication protocols have no significant effect as a mediator as shown by the result of an indirect effect. Communication protocols were found to be insignificant. The result was insignificant because the current research on communication protocols studied a manual system, not computerized systems like in the case of electronic clinical pathways. Also, the research by [45 Lo L. Teamwork and Communication in Healthcare. Canadian Patient Safety Institute Edmonton 2011; p. 68.] investigated and studied communication protocols alone without merging them with the electronic clinical pathways.

This paper proves, based on participants beliefs, that teamwork structure, H5, has a positive influence on the enhancement of teamwork communication. In addition, they believe information sharing influences teamwork communication enhancement, H9. This result shows the significance of information sharing’s influence on supporting teamwork communication enhancement. They also believe, that care planning has a positive influence on teamwork communication enhancement, H10. Likewise, they believe information exchange H11 has a positive influence on teamwork communication enhancement. In this case, the participants believe that information exchange can be done by activating the information sharing process.

This study has some limitations. First, this research was carried out in specific hospitals, which might limit the generalization of the results to other hospitals. Second, this research considered only physicians and nurses, who are the main users of clinical pathways. However, the study should be conducted to involve other healthcare stakeholders, such as administrators.

Nonetheless, and despite the limitations, this paper highlights many directions for future work such as the use of information exchange and communication protocols as mediation factors, which are likely to enhance teamwork communication by implementing electronic pathways.

CONCLUSION

The study addressed the factors that affect teamwork communication in healthcare by formulating a model according to the Socio-Technical Theory (STT) and Donabedian model. This study’s most important contribution is the development of a model that presents the attitude and beliefs of physicians and nurses in two hospitals in Jordan. The developed conceptual prototype presents the concept of electronic clinical pathways by merging communication protocols. Recommendations for Jordanian hospitals to apply and implement electronic clinical pathways are provided.

AUTHORS’ CONTRIBUTIONS

Dr. Ibrahim conceived the main idea for this work. Literature, data collection and analysis were done by Wasef Mater. Dr. Aldwairi contributed to the statistical analysis, results and discussion, submission and reviews, and final write-up.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGMENTS

This work was supported in part by the University Technology Malaysia and in part by Zayed University Research Office, Research Cluster Award #17079.

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